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1.  A Case of Incomplete Central Retinal Artery Occlusion Associated with Short Posterior Ciliary Artery Occlusion 
To our knowledge, incomplete central retinal artery occlusion associated with short posterior ciliary artery occlusion is extremely rare. Herein, we describe a case of a 62-year-old man who was referred to our hospital with of transient blindness in his right eye. At initial examination, the patient's best-corrected visual acuity was 18/20 in the right eye. Fundus examination showed multiple soft exudates around the optic disc and mild macular retinal edema in his right eye; however, a cherry red spot on the macula was not detected. Fluorescein angiography revealed delayed dye inflow into the nasal choroidal hemisphere that is supplied by the short posterior ciliary artery. The following day, the patient's visual acuity improved to 20/20. Soft exudates around the optic disc increased during observation and gradually disappeared. His hemodynamic parameters revealed subclavian steal syndrome as examined by cervical ultrasonography and digital subtraction angiography. We speculate that his transient blindness was due to ophthalmic artery spasms. In this particular case, spasms of the ophthalmic artery and occlusion of the short posterior ciliary artery occurred simultaneously. As the short posterior ciliary artery branches from the ophthalmic artery, the anatomical location of the lesion might be near the branching of both arteries.
doi:10.1155/2013/105653
PMCID: PMC3556421  PMID: 23365775
2.  Sudden unilateral visual loss after autologous fat injection into the nasolabial fold 
A 27-year-old female presented with sudden visual loss of her right eye after receiving an autologous fat injection into the right nasolabial fold. Fundus examination of the right eye showed multiple whitish patchy lesions with macular edema. Fluorescein angiogram showed deterioration of choroidal circulation with patchy choroidal filling and arm-to-retina circulation time and retinal arteriovenous passage time were delayed to 30 seconds and 20 seconds, respectively. There was no response in flash visual evoked potential (VEP). High dose steroid therapy (methylprednisolone 1 g/day/i.v.) was done and about 2 weeks later, the disc edema subsided and retinal arteriovenous passage time of fluorescein angiogram was normalized but there was no improvement in visual acuity. Absence of a cherry red spot, deterioration of choroidal circulation with patchy choroidal fillings seen in fluorescein angiogram, and no response in flash VEP suggests multiple choroidal infarction due to perfusion defect of the short posterior ciliary artery. The autologous fat injected is thought to have entered the dorsal nasal artery and the retrograde migration of the emboli to the ophthalmic artery might have caused the multiple occlusions of the short posterior ciliary artery.
PMCID: PMC2694002  PMID: 19668775
autologous fat injection; ciliary artery occlusion; ischemic optic neuropathy
3.  Traumatic Maculopathy 6 Months after Injury: A Clinical Case Report 
Case Reports in Ophthalmology  2014;5(1):78-82.
Purpose
This study aims to report a case of traumatic maculopathy in a 12-year-old male following blunt trauma in his left eye (LE) who presented 6 months after injury.
Methods
Retrospective and descriptive case report based on data from clinical records, patient observation and analysis of diagnostic tests.
Results
A previously healthy, 12-year-old male presented for a routine visit with complaints of a 2-month history of decreased visual acuity in his LE. Six months before the initial visit, he suffered blunt trauma to the LE during a struggle and had no medical observation. At the visit, best-corrected visual acuity (BCVA) in the LE was counting fingers and in the right eye, it was 20/20. Fundus examination of the LE showed a central macular lesion of 1 disc diameter with fibrosis, increased retinal thickness and intraretinal hemorrhage. Optical coherence tomography showed disruption of the inner/outer segment (IS/OS) photoreceptor junction, increased reflectivity, cell infiltration of the retinal wall and retinal pigment epithelium detachment. Retinal thickness was 289 μm at the site of the lesion. A fluorescein angiogram revealed early impregnation and late diffusion. High-dose steroid pulse therapy (intravenous methylprednisolone 500 mg for 3 days and oral prednisolone 30 mg, tapering for 10 days) was done. LE BCVA increased to 20/200, and retinal thickness decreased by 71 μm 1 week after treatment. Off-label intravitreal triamcinolone (IVTA; 0.05 ml/2 mg) was administered 2 weeks after oral treatment in an attempt to achieve additional improvement. Three weeks after IVTA, LE BCVA improved to 20/150 and retinal thickness decreased by 10 μm. Three months after the initial visit, LE BCVA was 20/125 and retinal thickness 208 μm.
Conclusion
We present a case of commotio retinae caused by an ocular blunt trauma 6 months before, with loss of BCVA. BCVA improved after oral steroids and IVTA. Nevertheless, fibrosis and disruption of the IS/OS junction in the macula limited the gain of BCVA.
doi:10.1159/000360692
PMCID: PMC3975199  PMID: 24707277
Traumatic maculopathy; Commotio retinae; Intravitreal triamcinolone acetonide
4.  Two Cases of Branch Retinal Arterial Occlusion After Carotid Artery Stenting in the Carotid Stenosis 
We describe two cases of branch retinal artery occlusion (BRAO) after carotid artery (CA) stenting.
Case 1: A 57-year-old man diagnosed with left neovascular glaucoma was admitted to our department for trabeculectomy (He had complained of decreased visual acuity (VA) in the left eye for a month). A preoperative neck angio CT scan showed bilateral CA stenosis. After CA stenting, he contracted visual defects on the right superior area of his right eye. Upon examination, VA with correction was found to be 1.0 (OD), but right fundoscopy revealed ischemic retina whitening along the inferior temporal arcade.
Case 2: A 64-year-old man received left CA stenting for severe stenosis in the Department of Neurology. The next day, he was referred to us for acute onset of a left naso-inferior visual field defect. Upon initial examination, his VA with correction was 0.8/0.16 (OD/OS) and fundoscopy revealed ischemic retina whitening at the superior posterior pole in the left eye.
It was not necessary to treat the BRAO in these cases because the foveal capillary network was not invaded at 2 month follow ups, VA was preserved in both cases.
In conclusion, ophthalmic evaluation is important after CA stenting because of a possible embolic occlusion of the retinal artery.
doi:10.3341/kjo.2009.23.1.53
PMCID: PMC2655744  PMID: 19337482
Retinal artery occlusion; Carotid stenosis; Carotid stenting
5.  Elongated Styloid Processes and Calcified Stylohyoid Ligaments in a Patient With Neck Pain: Implications for Manual Therapy Practice12 
Journal of Chiropractic Medicine  2014;13(2):128-133.
Objective
The purpose of this paper is to present a case of a patient with neck pain, tinnitus, and headache in the setting of bilateral elongated styloid processes (ESP) and calcified stylohyoid ligaments (CSL), how knowledge of this anatomical variation and symptomatic presentation affected the rehabilitation management plan for this patient, and to discuss the potential relevance of ESPs and CSLs to carotid artery dissection.
Clinical features
A 29-year-old male military helicopter mechanic presented for chiropractic care for chronic pain in the right side of his neck and upper back, tinnitus, and dizziness with a past history of right side parietal headaches and tonsillitis. Conventional radiographs showed C6 and C7 spinous process fractures, degenerative disc disease at C6/7, and an elongated right styloid process with associated calcification of the left stylohyoid ligament. Volumetric computerized tomography demonstrated calcification of the stylohyoid ligaments bilaterally.
Intervention and outcome
Given the proximity of the calcified stylohyoid apparatus to the carotid arteries, spinal manipulation techniques were modified to minimize rotation of the neck. Rehabilitation also included soft tissue mobilization and stretching, corrective postural exercises, and acupuncture. An otolaryngologist felt that the symptoms were not consistent with Eagle syndrome and the tinnitus was associated with symmetric high frequency hearing loss, likely due to occupational noise exposure. Initially, the patient's symptoms improved but plateaued by the fifth visit.
Conclusion
Neck pain in the presence of ESPs and CSLs can be associated with Eagle syndrome, which can include ipsilateral head and neck pain, odynophagia, dysphagia, and cerebrovascular symptoms. This case, initially thought to be Eagle syndrome, highlights proper diagnostic workup for this condition and presents potential contraindications to consider with regard to cervical spine manipulation in such patients. Manual therapy precautions pertaining to cervical spine manipulation may be appropriate in cases involving ESPs and calcified stylohyoid ligaments.
doi:10.1016/j.jcm.2014.06.006
PMCID: PMC4322018
Neck pain; Manipulation, spinal; Elongated styloid process syndrome; Carotid artery, internal
6.  Retrospective study of threshold time for the conventional treatment of branch retinal artery occlusion 
Purpose
To investigate the medical backgrounds of patients and the treatment periods from the onset of branch retinal artery occlusion to obtaining improved final visual acuity.
Methods
This was a retrospective case series study. A total of 68 consecutive patients (69 eyes) with branch retinal artery occlusion who visited Tokyo Medical University Hospital from 2007 to 2012 were included in this study. All patients underwent ophthalmic examinations and visual acuity tests. We reviewed their medical records for systemic conditions, as well as the periods from onset of symptoms to treatment. Participants were categorized into 2 groups: group A (n=36), which received any treatment within 24 hours from onset, and group B (n=33), which visited our hospital after 24 hours from onset. Best corrected visual acuity (BCVA) changes from the first to final visit and the relationships between systemic condition and visiting time to BCVA were assessed.
Results
At the first visit, 59% of the patients had BCVA over 20/40; the ratio was increased to 74% at the final visit. BCVA improved more than 2 lines for 35% of the patients and was unchanged for 57% of those receiving conventional treatment. BCVA over 20/40 was significantly lower in hyperlipidemia patients. Hypertension, diabetes mellitus, and significant carotid stenosis were not correlated. The mean BCVA at baseline (0.91±1.03) significantly recovered to 0.35±0.91 after treatment in group A (P<0.001, Student’s t-test). The mean BCVA at baseline (0.30±0.64) was 0.25±0.61 at the final visit in group B (no significant change).
Conclusion
Conventional treatment within 24 hours from onset was acceptable for branch retinal artery occlusion.
doi:10.2147/OPTH.S70468
PMCID: PMC4181636  PMID: 25284974
branch retinal artery occlusion; BRAO; golden period; treatment time
7.  Bilateral Ophthalmic Artery Occlusion in Rhino-Orbito-Cerebral Mucormycosis 
Purpose
To report a case of bilateral ophthalmic artery occlusion in rhino-orbito-cerebral mucormycosis.
Methods
Reviewed clinical charts, photographs, and fluorescein angiography.
Results
An 89-year-old man with poorly controlled diabetes developed sudden bilateral ptosis, complete ophthalmoplegia of the right eye, and superior rectus palsy of the left eye. Brain and orbit magnetic resonance imaging showed midbrain infarction and mild diffuse sinusitis. On the 2nd day of hospitalization, sudden visual loss and light reflex loss developed. There were retinal whitening, absence of retinal arterial filling, and a total lack of choroidal perfusion on fluorescein angiography of the right eye. The left eye showed a cherry red spot in the retina and the absence of retinal arterial filling and partial choroidal perfusion on fluorescein angiography. On rhinologic examination, mucormyosis was noticed. Despite treatment, visual acuity and light reflex did not recover and he died 4 days after admission.
Conclusions
Bilateral ophthalmic artery occlusion can occur in rhino-orbital-cerebral mucormycosis.
doi:10.3341/kjo.2008.22.1.66
PMCID: PMC2629957  PMID: 18323710
Bilateral ophthalmic artery occlusion; Mucormycosis
8.  Central retinal artery occlusion in association with fibromuscular dysplasia 
A 14 year-old female, whose chief complaint was severe vision loss in the right eye for 2 days, presented to the Clinic of Ophthalmology of Fatih Sultan Mehmet Education and Research Hospital. The patient had been attending follow-up visits for 4 years, following a diagnosis of fibromuscular dysplasia by the Clinic of Pediatrics. The patient underwent a complete ophthalmo-logic, angiographic, hematologic, and systemic evaluation. Fundus fluorescein angiography was performed immediately, because of the cherry-red spot sign in the macula of the right eye. Fundus fluorescein angiography revealed evidence of marked stasis of the retinal arterial circulation in the right eye. Best corrected visual acuity was 20/400 in the right eye and 20/20 in the left eye.
doi:10.2147/OPTH.S55011
PMCID: PMC3839843  PMID: 24293990
retina; artery; occlusion; fibromuscular; dysplasia
9.  Asymmetric severity of diabetic retinopathy in Waardenburg syndrome 
A 30-year-old female patient was referred to our institution due to vitreous hemorrhage. Best corrected visual acuity of her right and left eyes at her initial visit was 10/20 and 20/20, respectively. Although hypochromic iris was observed in the superior iris between the 10 and 2 o’clock positions in her right eye, her entire left eye exhibited hypochromic iris. Hypopigmentation of the fundus was seen in the superior part of her right eye. This eye also had a huge neovascularization on the optic disc that was 7 discs in diameter. Conversely, her left fundi showed hypopigmentation of the fundus in the entire region of the left eye, and dot hemorrhages were observed all over the left fundi, although no neovascularization could be seen microscopically. Fluorescein angiography showed a huge neovascularization in the right eye and a tiny neovascularization in the left eye. Gene analysis revealed the presence of the PAX3 gene homeobox domain mutation, which led to her being diagnosed as Waardenburg syndrome type 1. Magnetic resonance angiography showed there was no obstructive region at either of the internal carotid arteries and ophthalmic arteries. The severity of the diabetic retinopathy appeared to be correlated with the degree of hypopigmentation in the posterior fundus. We speculate that hypopigmentation of the fundus in Waardenburg syndrome may be responsible for the reduction in retinal metabolism, which led to a reduction in oxygen consumption and prevented further aggravation of the diabetic retinopathy. Only laser treatments using short wavelengths was effective in this case. While the extinction coefficient for hemoglobin when using green light is higher than when using yellow light, the differences between these wavelengths tend to disappear when oxygenated hemoglobin is present. To the best of the authors’ knowledge, this is the first case report of a patient with Waardenburg syndrome and diabetic retinopathy.
doi:10.2147/OPTH.S27490
PMCID: PMC3245192  PMID: 22205830
asymmetry; diabetic retinopathy; Waardenburg syndrome; albinism; hypopigmentation
10.  A Case of Diode Laser Photocoagulation in the Treatment of Choroidal Metastasis of Breast Carcinoma 
To report a single case of improvement on choroidal metastasis of breast cancer after laser photocoagulation. A 52-year-old female patient who complained of visual disturbance of the right eye with multiple states of metastasis of breast carcinoma. On initial examination, the right best-corrected visual acuity was 0.63. Right fundoscopy revealed an elevated mass-like lesion temporal to the macule with serous retinal detachment. The mass had a 3.5-disc diameter. A right fluorescein angiogram revealed hypofluorescence during the prearterial and arteriovenous phase and hyperfluorescence during the venous phase. The venous phase showed almost total masking of background choroidal fluorescence at the elevated lesion because of leakage and neovascularization. The patient was treated 4 times by diode laser photocoagulation in addition to chemotherapy. Fifty days after the diode laser treatments, the funduscopy examination and fluorescein angiogram revealed that the serous retinal detachment had been absorbed, the choroid had become flat, the lesion had been reduced in size and hyperfluorescence. The right best-corrected visual acuity was improved to 0.8. Laser photocoagulation appears not to cause any problems for the patient and may be an efficient treatment for patients with choroidal breast carcinoma.
doi:10.3341/kjo.2008.22.3.187
PMCID: PMC2629897  PMID: 18784448
Breast carcinoma; Intraocular metastatic tumor; Laser therapy
11.  Vision Loss and RNFL Thinning after Internal Carotid Arter Occlusion and Middle Cerebral Artery Infarction 
Acta Informatica Medica  2014;22(6):413-414.
Introduction:
Ischaemic, traumatic or neoplasmic damage to the optic chiasm, optic tract or lateral geniculate nucleus affects the retinal ganglion cell (RGC) axons, detected as reduced retinal nerve fiber layer (RNFL) thickness around the optic nerve head. We report a case of vision loss and reduced RNFL thickness after internal carotid artery (ICA) occlusion and middle cerebral artery (MCA) infarction.
Case report:
A 33-year-old woman with a 3-month history of vision loss in right eye and left hemiplegia. The best corrected visual acuity was 1.0 in left eye and there was no light perception in the right eye. Ocular motility, intra-ocular pressure, anterior segments were normal in the both eyes. Her fundus examinations were normal except optic atrophy in the right eye. Visual field test was not performed because of cooperation difficulties. Magnetic resonance imaging (MRI) revealed an infarction of the right MCA. Computed tomographic angiography showed right ICA occlusion. Optical coherence tomography (OCT) demonstrated 6 clock hours of RNFL thinning in the right eye. Average RNFL thickness of the right and left eyes were 53µm, 96 µm respectively.
Conclusions:
Our findings show that a relatively short period of ICA occlusion and MCA infarction can cause vision loss and thinning of the RNFL.
doi:10.5455/aim.2014.22.413-414
PMCID: PMC4315637
retinal nerve fiber layer; internal carotid arter occlusion; middle cerebral artery infarction
12.  Long-term remission of myopic choroidal neovascular membrane after treatment with ranibizumab: a case report 
Introduction
Myopia has become a big public health problem in certain parts of the world. Sight-threatening complications like choroidal neovascularisation membranes occur in up to 10% of pathological myopia, and natural history studies show a trend towards progressive visual loss. There are long-term financial and quality-of-life implications in this group of patients, and treatment strategies should aim for long-term preservation of vision.
Case presentation
A 56-year-old Caucasian woman presented with a best-corrected visual acuity of 6/6-1 in her right eye and 6/24 in her left. Fundal examination revealed pathological myopia in both eyes and an elevated lesion associated with pre-retinal haemorrhage in the left macula. Ocular coherence tomography and fundus fluorescein angiogram confirmed a subfoveal classic choroidal neovascularisation membrane. The patient decided to proceed with intravitreal ranibizumab (0.5 mg) therapy. One month after treatment, best-corrected visual acuity improved to 6/12 in her left eye, with complete resolution subretinal fluid on ocular coherence tomography. After three months, best-corrected visual acuity further improved to 6/9, which was maintained up to 16 months post-treatment.
Conclusion
We suggest intravitreal ranibizumab as an alternative treatment for long-term remission of myopic choroidal neovascular membrane. It also suggests that myopic choroidal neovascularisation membranes may require fewer treatments to achieve sustained remission. Furthermore, this could serve as a feasible long-term management option if used in conjunction with ocular coherence tomography.
doi:10.1186/1752-1947-3-84
PMCID: PMC2783083  PMID: 19946560
13.  Macular involvement in patients with Behçet’s uveitis 
Purpose
The purpose of this study is to assess macular involvement in patients with Behçet’s uveitis.
Methods
The study included 65 patients (120 eyes) with Behçet’s uveitis. All patients underwent detailed ophthalmic examination, including dilated biomicroscopic fundus examination, fundus photography, fluorescein angiography, and optical coherence tomography. Follow-up ranged from 6 to 46 months (mean 20 months).
Results
At initial examination, 29 eyes (24.1 %) had macular involvement including macular edema (16 eyes, 13.3 %), serous retinal detachment (SRD; five eyes, 4.1 %), active retinitis (three eyes, 2.5 %), macular hole (three eyes, 2.5 %), macular atrophy (two eyes, 1.6 %), macular ischemia (one eye, 0.8 %), epiretinal membrane (one eye, 0.8 %), branch retinal vein occlusion involving the macula (three eyes, 2.5 %), and branch retinal artery occlusion involving the macula (two eyes, 1.6 %). During follow-up, 22 eyes (18.3 %) developed macular complications including macular edema (ten eyes, 8.3 %), SRD (four eyes, 3.3 %), active retinitis (two eyes, 1.6 %), severe macular atrophy (two eyes, 1.6 %), macular ischemia (three eyes, 2.5 %), macular hole (one eye, 0.8 %), epiretinal membrane (two eyes, 1.6 %), and subretinal fibrosis (one eye, 0.8 %). Branch retinal vein occlusion involving the macula developed in two eyes (1.6 %). Final best corrected visual acuity in patients with macular involvement ranged from 20/400 to 20/25 (mean 20/80).
Conclusions
Macular edema and other vision-threatening macular complications are common in Behçet’s uveitis. Macular damage is often irreversible, causing permanent visual impairment. Early and appropriate treatment of Behçet’s uveitis is mandatory to reduce the risk of visual impairment due to macular involvement.
doi:10.1007/s12348-012-0075-9
PMCID: PMC3438295  PMID: 22549340
Behçet’s uveitis; Macula; Macular edema; Optical coherence tomography; Visual impairment
14.  Branch retinal artery occlusion secondary to dengue fever 
Dengue is known to affect the posterior segment of the eye, with a range of hemorrhagic and inflammatory sequelae. A 28-year-old lady convalescing from dengue fever complained of unilateral blurring of inferior visual field. She was evaluated clinically and with fluorescein angiography. Her best-corrected visual acuity was 20/20 bilaterally. Fundus examination revealed a branch retinal artery occlusion in the right eye. Fluorescein angiogram confirmed the clinical diagnosis; and also revealed a late staining and leakage from the affected arterial segment. The patient maintained status quo over a follow-up of six months. We report a major vascular occlusion complicating classic dengue fever even in the absence of severe systemic manifestations.
PMCID: PMC2636058  PMID: 18158412
Dengue; retinal artery occlusion; vasculitis
15.  Septic Cavernous Thrombosis Due to Campylobacter Rectus Infection 
Introduction:
Cavernous sinus thrombosis is a rare but serious disease associated with significant morbidity and mortality. Early recognition and prompt treatment is necessary to improve patient outcomes in this potentially fatal disease.
Case Report:
A 55-year-old man visiting from mainland China with no significant past medical history presented with eight days of headache. One day prior to admission, the patient developed diplopia and ptosis of his left eye. Physical examination revealed a fixed, dilated left pupil and left third, fourth, and sixth nerve palsies with loss of sensation in the left supraorbital region. Initial magnetic resonance imaging (MRI) of the brain showed fullness of the left cavernous sinus and dilated left superior ophthalmic vein consistent with cavernous sinus thrombosis. Treatment was initiated with broad spectrum antibiotics, high-dose corticosteroids, and anticoagulants.
Hours after admission, he developed new proptosis, ophthalmoplegia, and marked chemosis of his right eye. Bilateral carotid artery angiogram ruled out indirect or direct carotid cavernous fistula. Computed tomography (CT) angiogram of the neck showed right internal jugular vein thrombosis extending into the right sigmoid sinus, while CT of the chest revealed solid and cavitary pulmonary nodules consistent with septic pulmonary emboli. Repeat MRI two days later showed progression of thrombosis to the contralateral cavernous sinus and superior ophthalmic vein. MRI venogram showed decreased, and in some portions, lack of flow in the right transverse, sigmoid sinuses and visualized internal jugular vein.
Blood cultures eventually grew Campylobacter rectus identified by 16S rRNA sequencing. Additional history revealed that the patient had an uncomplicated tooth extraction of a decayed upper left molar 3 months ago. As Campylobacter rectus is a member of the human oral flora associated with human periodontal disease, we hypothesized that the patient's infection likely started from left upper molar removal causing bacteremia and resulting in left cavernous sinus and right internal jugular vein thromboses with septic pulmonary emboli. The patient's condition improved and he was discharged from hospital to continue medical care in China.
Discussion:
Despite the very few cases of invasive Campylobacter rectus infections reported in literature, this case illustrates that Campylobacter rectus can be pathogenic. Dental infections may result in serious complications and an odontogenic source of infection should always be considered in patients with cavernous sinus thrombosis.
PMCID: PMC4175952
16.  Retinal Artery Occlusion 
Ophthalmology  2009;116(10):1928-1936.
Objective
To investigate systematically the various associated systemic and ophthalmic abnormalities in different types of retinal artery occlusion (RAO).
Design
Cohort study.
Participants
439 consecutive untreated patients (499 eyes) with RAO, first seen in our clinic from 1973 to 2000.
Methods
At first visit, all patients had a detailed ophthalmic and medical history, and comprehensive ophthalmic evaluation. Visual evaluation was done by recording visual acuity, using the Snellen visual acuity chart, and visual fields with a Goldmann perimeter. Initially they also had carotid Doppler/angiography and echocardiography. The same ophthalmic evaluation was performed at each follow-up visit.
Main Outcome Measures
Demographic features, associated systemic and ophthalmic abnormalities and sources of emboli in various types of RAO.
Results
RAO was classified into various types of central (CRAO) and branch (BRAO) artery occlusion. In both nonarteritic CRAO and BRAO the prevalence of diabetes mellitus, arterial hypertension, ischemic heart disease, and cerebrovascular accidents were significantly higher compared to the prevalence of these conditions in the matched US population (all p<0.0001). Smoking prevalence, compared to the US population, was significantly higher for males (p=0.001) with nonarteritic CRAO and for females with BRAO (p=0.02). Ipsilateral internal carotid artery had ≥50% stenosis in 31% of nonarteritic CRAO patients and 30% of BRAO, and plaques in 71% of nonarteritic CRAO and 66% of BRAO. Abnormal echocardiogram with embolic source was seen in 52% of nonarteritic CRAO and 42% of BRAO. Neovascular glaucoma developed in only 2.5% of nonarteritic CRAO eyes.
Conclusion
This study showed that in CRAO as well as BRAO the prevalence of various cardiovascular diseases and smoking was significantly higher compared to the prevalence of these conditions in the matched US population. Embolism is the most common cause of CRAO and BRAO; plaque in the carotid artery is usually the source of embolism and less commonly the aortic and/or mitral valve. The presence of plaques in the carotid artery is generally of much greater importance than the degree of stenosis in the artery. Contrary to the prevalent misconception, there is no cause-and-effect relationship between CRAO and neovascular glaucoma.
doi:10.1016/j.ophtha.2009.03.006
PMCID: PMC2757505  PMID: 19577305
17.  Central retinal artery occlusion following severe blow-out fracture in young adult 
A 20-year-old woman was involved in a traffic accident while riding a motorcycle. The vision in her right eye was severely reduced. At the first examination, the eyelids of her right eye were severely swollen, and the eye could barely be seen. The fundus was not visible. She had no light perception in her vision. Computed tomography revealed a severe blow-out fracture in her right eye. Surgery was immediately performed to correct the fracture and the eye globe was replaced in the orbit. On the fourth postoperative day, the right fundus was visible and a cherry-red spot and milky-white edema were seen. Fluorescein angiography showed an arterial filling defect. Four months later, her visual acuity was light perception. Our case shows that a central retinal artery occlusion can be a complication of a blow-out fracture of the lower orbital wall and can lead to severe visual loss even with early surgical repair.
PMCID: PMC2709037  PMID: 19668585
central retinal artery occlusion; blow out fracture; trauma; young adult
18.  Cystoid puncture for chronic cystoid macular oedema 
The British Journal of Ophthalmology  2007;91(8):1062-1064.
Objective
To evaluate the new surgical technique of cystoid macular oedema puncture (CMOP) in patients with longstanding cystoid macular oedema refractory to standard treatments.
Design
Interventional, retrospective case series
Methods
Retrospective review of patients with chronic cystoid macular oedema from vascular retinopathy for whom maximal medical or surgical treatment failed and who underwent pars plana vitrectomy and CMOP. Clinical findings, best‐corrected Snellen visual acuity, stereo colour fundus photography, intravenous fluorescein angiograms, and optical coherence tomography were obtained before and after treatment to evaluate the efficacy and safety of the treatment.
Results
Seven patients were included in the study. Cystoid macular oedema was due to diabetic retinopathy in five patients, central retinal vein occlusion in one patient and branch retinal vein occlusion in one patient. Preoperative intravitreal steroids failed for all patients, and three patients also had focal grid photocoagulation. Previous pars plana vitrectomy, with elevation of the posterior hyaloid, internal limiting membrane peeling, and intravitreal steroid injection, had failed in three patients. The median time to CMOP was 488 days. Resolution or improvement of cystoid oedema occurred in all patients as determined by fluorescein angiography or optical coherence tomography, or both. However, visual acuity was unchanged in five patients, declined in one patient and stable in one patient.
Conclusions
Although cystoid macular oedema does improve quantitatively after CMOP, the technique fails to improve visual acuity in patients.
doi:10.1136/bjo.2006.101790
PMCID: PMC1954821  PMID: 17229807
macular oedema; cystoid macular oedema; diabetic retinopathy; cystoid puncture; retinal vein occlusion
19.  Improvement in hearing after chiropractic care: a case series 
Background
The first chiropractic adjustment given in 1895 was reported to have cured deafness. This study examined the effects of a single, initial chiropractic visit on the central nervous system by documenting clinical changes of audiometry in patients after chiropractic care.
Case presentation
Fifteen patients are presented (9 male, 6 female) with a mean age of 54.3 (range 34–71). A Welch Allyn AudioScope 3 was used to screen frequencies of 1000, 2000, 4000 and 500 Hz respectively at three standard decibel levels 20 decibels (dB), 25 dB and 40 dB, respectively, before and immediately after the first chiropractic intervention. Several criteria were used to determine hearing impairment. Ventry & Weinstein criteria of missing one or more tones in either ear at 40 dB and Speech-frequency criteria of missing one or more tones in either ear at 25 dB.
All patients were classified as hearing impaired though greater on the right. At 40 dB using the Ventry & Weinstein criteria, 6 had hearing restored, 7 improved and 2 had no change. At 25 dB using the Speech-frequency criteria, none were restored, 11 improved, 4 had no change and 3 missed a tone.
Conclusion
A percentage of patients presenting to the chiropractor have a mild to moderate hearing loss, most notably in the right ear. The clinical progress documented in this report suggests that manipulation delivered to the neuromusculoskeletal system may create central plastic changes in the auditory system.
doi:10.1186/1746-1340-14-2
PMCID: PMC1395318  PMID: 16423302
20.  Branch retinal artery occlusion associated with posterior uveitis 
Background
The purpose of this study is to report the clinical features and visual outcome of branch retinal artery occlusion (BRAO) associated with posterior uveitis. This is a retrospective study including the 18 eyes of 18 patients. All patients underwent a complete ophthalmic evaluation. Fundus photography, fluorescein angiography, and visual field testing were performed in all cases.
Results
Diseases associated with BRAO included active ocular toxoplasmosis in 7 patients, rickettsiosis in 4, Behçet’s uveitis in 2, West Nile virus infection in 1, idiopathic retinal vasculitis in 1, Crohn’s disease in 1, ocular tuberculosis in 1, and idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome in 1 patient. The mean initial visual acuity was 20/50. BRAO involved the first order retinal artery in 33.3% of the eyes, the second order retinal artery in 33.3%, an arteriole in 27.8%, and a cilioretinal artery in 5.5%. The macula was involved in 44.4% of the eyes and an acute focus of retinitis or retinochoroiditis was associated to BRAO in 55.5%. Repermeabilization of the occluded artery occurred in all patients with permanent scotomas in the corresponding visual field. The mean visual acuity at last visit was 20/32.
Conclusions
BRAO, with subsequent visual impairment, may occur in the eyes with posterior uveitis. Physicians should be aware of such vision-threatening complication of infectious and inflammatory eye diseases.
doi:10.1186/1869-5760-3-16
PMCID: PMC3605076  PMID: 23514435
Branch retinal artery occlusion; Posterior uveitis; Fluorescein angiography; Visual impairment
21.  Reflex control of the spine and posture: a review of the literature from a chiropractic perspective 
Objective
This review details the anatomy and interactions of the postural and somatosensory reflexes. We attempt to identify the important role the nervous system plays in maintaining reflex control of the spine and posture. We also review, illustrate, and discuss how the human vertebral column develops, functions, and adapts to Earth's gravity in an upright position. We identify functional characteristics of the postural reflexes by reporting previous observations of subjects during periods of microgravity or weightlessness.
Background
Historically, chiropractic has centered around the concept that the nervous system controls and regulates all other bodily systems; and that disruption to normal nervous system function can contribute to a wide variety of common ailments. Surprisingly, the chiropractic literature has paid relatively little attention to the importance of neurological regulation of static upright human posture. With so much information available on how posture may affect health and function, we felt it important to review the neuroanatomical structures and pathways responsible for maintaining the spine and posture. Maintenance of static upright posture is regulated by the nervous system through the various postural reflexes. Hence, from a chiropractic standpoint, it is clinically beneficial to understand how the individual postural reflexes work, as it may explain some of the clinical presentations seen in chiropractic practice.
Method
We performed a manual search for available relevant textbooks, and a computer search of the MEDLINE, MANTIS, and Index to Chiropractic Literature databases from 1970 to present, using the following key words and phrases: "posture," "ocular," "vestibular," "cervical facet joint," "afferent," "vestibulocollic," "cervicocollic," "postural reflexes," "spaceflight," "microgravity," "weightlessness," "gravity," "posture," and "postural." Studies were selected if they specifically tested any or all of the postural reflexes either in Earth's gravity or in microgravitational environments. Studies testing the function of each postural component, as well as those discussing postural reflex interactions, were also included in this review.
Discussion
It is quite apparent from the indexed literature we searched that posture is largely maintained by reflexive, involuntary control. While reflexive components for postural control are found in skin and joint receptors, somatic graviceptors, and baroreceptors throughout the body, much of the reflexive postural control mechanisms are housed, or occur, within the head and neck region primarily. We suggest that the postural reflexes may function in a hierarchical fashion. This hierarchy may well be based on the gravity-dependent or gravity-independent nature of each postural reflex. Some or all of these postural reflexes may contribute to the development of a postural body scheme, a conceptual internal representation of the external environment under normal gravity. This model may be the framework through which the postural reflexes anticipate and adapt to new gravitational environments.
Conclusion
Visual and vestibular input, as well as joint and soft tissue mechanoreceptors, are major players in the regulation of static upright posture. Each of these input sources detects and responds to specific types of postural stimulus and perturbations, and each region has specific pathways by which it communicates with other postural reflexes, as well as higher central nervous system structures. This review of the postural reflex structures and mechanisms adds to the growing body of posture rehabilitation literature relating specifically to chiropractic treatment. Chiropractic interest in these reflexes may enhance the ability of chiropractic physicians to treat and correct global spine and posture disorders. With the knowledge and understanding of these postural reflexes, chiropractors can evaluate spinal configurations not only from a segmental perspective, but can also determine how spinal dysfunction may be the ultimate consequence of maintaining an upright posture in the presence of other postural deficits. These perspectives need to be explored in more detail.
doi:10.1186/1746-1340-13-16
PMCID: PMC1198239  PMID: 16091134
Cervical spine; Posture; Reflex
22.  Inappropriate use of the title 'chiropractor' and term 'chiropractic manipulation' in the peer-reviewed biomedical literature 
Background
The misuse of the title 'chiropractor' and term 'chiropractic manipulation', in relation to injury associated with cervical spine manipulation, have previously been reported in the peer-reviewed literature.
The objectives of this study were to -
1) Prospectively monitor the peer-reviewed literature for papers reporting an association between chiropractic, or chiropractic manipulation, and injury;
2) Contact lead authors of papers that report such an association in order to determine the basis upon which the title 'chiropractor' and/or term 'chiropractic manipulation' was used;
3) Document the outcome of submission of letters to the editors of journals wherein the title 'chiropractor', and/or term 'chiropractic manipulation', had been misused and resulted in the over-reporting of chiropractic induced injury.
Methods
One electronic database (PubMed) was monitored prospectively, via monthly PubMed searches, during a 12 month period (June 2003 to May 2004). Once relevant papers were located, they were reviewed. If the qualifications and/or profession of the care provider/s were not apparent, an attempt was made to confirm them via direct e-mail communication with the principal researcher of each respective paper. A letter was then sent to the editor of each involved journal.
Results
A total of twenty four different cases, spread across six separate publications, were located via the monthly PubMed searches. All twenty four cases took place in one of two European countries.
The six publications consisted of four case reports, each containing one patient, one case series, involving twenty relevant cases, and a secondary report that pertained to one of the four case reports. In each of the six publications the authors suggest the care provider was a chiropractor and that each patient received chiropractic manipulation of the cervical spine prior to developing symptoms suggestive of traumatic injury.
In two of the four case reports contact with the principal researcher revealed that the care provider was not a chiropractor, as defined by the World Federation of Chiropractic. The authors of the other two case reports did not respond to my communications. In the case series, which involved twenty relevant cases, the principal researcher conceded that the term chiropractor had been inappropriately used and that his case series did not relate to chiropractors who had undergone appropriate formal training. The author of the secondary report, a British Medical Journal editor, conceded that he had misused the title chiropractor. Letters to editors were accepted and published by all four journals to which they were sent. To date one of the four journals has published a correction.
Conclusion
The results of this year-long prospective review suggests that the words 'chiropractor' and 'chiropractic manipulation' are often used inappropriately by European biomedical researchers when reporting apparent associations between cervical spine manipulation and symptoms suggestive of traumatic injury. Furthermore, in those cases reported here, the spurious use of terminology seems to have passed through the peer-review process without correction. Additionally, these findings provide further preliminary evidence, beyond that already provided by Terrett, that the inappropriate use of the title 'chiropractor' and term 'chiropractic manipulation' may be a significant source of over-reporting of the link between the care provided by chiropractors and injury. Finally, editors of peer-reviewed journals were amenable to publishing 'letters to editors', and to a lesser extent 'corrections', when authors had inappropriately used the title 'chiropractor' and/or term 'chiropractic manipulation'.
doi:10.1186/1746-1340-14-16
PMCID: PMC1570468  PMID: 16925822
23.  Superselective ophthalmic artery fibrinolytic therapy for the treatment of central retinal vein occlusion 
The British Journal of Ophthalmology  2000;84(12):1387-1391.
AIM—To study the effect of superselective ophthalmic artery fibrinolysis as a treatment for central retinal vein occlusion (CRVO).
METHODS—Retrospective, university based single centre study. The charts of 26 eyes of 26 patients treated were reviewed. Among the 26 patients, there were nine cases of combined artery and vein occlusion, three cases of combined cilioretinal artery and CRVO, and 14 cases of classic CRVO. Complete preoperative and postoperative ophthalmological examination and fluorescein angiography were performed in all cases. The therapeutic procedure comprised the infusion of urokinase through a microcatheter into the ostium of the ophthalmic artery, via a femoral artery approach. The main outcome measure was the improvement in visual acuity 48 hours after the procedure.
RESULTS—Six eyes of six patients exhibited significant improvement in visual acuity immediately after the fibrinolysis procedure. Among them, four had a initial funduscopic appearance suggestive of combined occlusion of the central retinal artery (CRAO) and vein. For these patients, the visual benefit was maintained in the long term. Intravitreal haemorrhage occurred in two patients. There were no extraocular complications linked to the procedure.
CONCLUSIONS—Selective ophthalmic artery infusion of urokinase was followed by improvement in VA in six out of 26 cases of CRVO. Eyes with combined CRAO and CRVO with recent visual loss appeared to be the most responsive. This treatment did not prevent the occurrence of ischaemia in the failure cases. The efficacy of in situ fibrinolysis for treatment of CRVO needs to be further evaluated in a controlled study.


doi:10.1136/bjo.84.12.1387
PMCID: PMC1723344  PMID: 11090479
24.  Branch Retinal Artery Occlusion: Natural History of Visual Outcome 
Ophthalmology  2009;116(6):1188-94.e1-4.
Objective
To investigate systematically the natural history of visual outcome in branch retinal artery occlusion (BRAO).
Design
Cohort study.
Participants
199 consecutive untreated patients (212 eyes) with BRAO, first seen in our clinic from 1973 to 2000.
Methods
At first visit, all patients had a detailed ophthalmic and medical history, and comprehensive ophthalmic evaluation. Visual evaluation was done by recording visual acuity, using the Snellen visual acuity chart, and visual fields with a Goldmann perimeter. The same ophthalmic evaluation was performed at each follow-up visit.
Main Outcome Measures
Visual acuity and visual fields.
Results
BRAO was classified into permanent (133 eyes) and transient (18 eyes) BRAO and cilioretinal artery occlusion (CLRAO – 61 eyes). In eyes with permanent BRAO, of the 61 eyes seen within 7 days of onset, initial visual acuity was 20/40 or better in 74%, central scotoma in 20%, central inferior altitudinal defect in 13%, and inferior nasal and superior sector defects in 29% and 24% respectively. Of those with follow-up, in the eyes with visual acuity worse than 20/40, it improved in 79% (11 of 14), abnormal central visual field defect improved in 47%, and abnormal peripheral visual field defect improved in 52%. Of the 18 eyes with transient BRAO, initially 17 (94%) had visual acuity of 20/40 or better and one (6%) worse that 20/40, which improved to 20/30 on follow-up. Of the 11 eyes with nonarteritic CLRAO alone, visual acuity was worse than 20/40 in 3 eyes – that improved to 20/40 or better in all during follow-up. In CLRAO on follow-up of 9 eyes, the central field improved in 4. When CLRAO was associated with retinal vein occlusion (38 eyes) or giant cell arteritis (12 eyes), visual findings were influenced by the associated diseases.
Conclusion
These findings show that visual acuity of 20/40 or better is seen initially in 74% of permanent BRAO, 94% of transient BRAO and 73% of nonarteritic CLRAO alone; and finally on follow-up, in 89%, 100% and 100% respectively. The effectiveness of various treatment modalities for visual outcome has to be judged against this background.
doi:10.1016/j.ophtha.2009.01.015
PMCID: PMC2759688  PMID: 19376586
25.  Central Serous Chorioretinopathy with Subretinal Deposition of Fibrin-Like Material and Its Prompt Response to Ranibizumab Injections 
Case Reports in Ophthalmology  2011;2(1):59-64.
Purpose
Central serous chorioretinopathy (CSCR) manifests as neurosensory detachment of the macula and can be attributed to focal or multifocal leakage in the retinal pigment epithelium (RPE). Fibrin accumulation in the subretinal space is an unusual and heretofore unreported visually damaging manifestation of severe CSCR.
Methods
The patient was followed up with the use of biomicroscopy, fluorescein angiography, and optical coherence tomography (OCT).
Results
A 32-year-old woman was referred to our department complaining of metamorphopsia and decreased visual acuity in the right eye. Best-corrected visual acuity (BCVA) was 20/40 in the right eye and 20/20 in the left eye. Biomicroscopy revealed an irregularly shaped foveal elevation and wrinkling in the right eye. OCT showed a steep neurosensory retina elevation with a highly reflective material accumulation in the subretinal space, presumably fibrin. Our diagnosis was CSCR complicated by subretinal fibrin accumulation. Since most of these cases resolve spontaneously, the patient was kept under observation; 1 month later, the fibrin accumulation had expanded subfoveally (BCVA 20/200). The patient was offered 3 intravitreal ranibizumab injections. After the initial injection, BCVA improved to 20/50 and, after the 3 injections, to 20/30. Two months later (BCVA 20/30), fresh leakage was observed at the margin of the original lesion, and an additional intravitreal ranibizumab injection was performed. After another 2 months, BCVA stabilized at 20/25 and remained stable throughout the 12 months after the initial injection.
Conclusions
Prompt recognition of CSCR complicated by subretinal fibrin and immediate intervention may result in recovery from this potentially devastating complication. Ranibizumab may be an alternative treatment option in the management of refractory CSCR complicated by subretinal fibrin accumulation.
doi:10.1159/000324701
PMCID: PMC3072172  PMID: 21475646
Central serous chorioretinopathy; Fibrin; Ranibizumab; Optical coherence tomography

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